EFTA00314084.pdf

C-cl rman De of 1.00;', ICr School c• Meacire a: S na. O. (2:2i 2e-9955 Mount Sinai Jeffrey Epstein IIEF NAME DATE OF BIRTH-lain 20, 1953 AGE 6 3 9 East 71st Street ADDRESS NY, NY 10021 212.750.9895 Patient Questionnaire TELEPHONE These questions ask about the effects that your erection problems have had on your sex life over the last four weeks. Please try to answer the questions as honestly and as clearly as you are able. Your answers will help your doctor to choose the most effective treatment suited to your condition. In answering the questions, the following definitions apply: • sexual activity includes intercourse, caressing, foreplay, & masturbation. • sexual intercourse is defined as sexual penetration of your partner. • sexual stimulation includes situation such as foreplay, erotic pictures, etc. • ejaculation is the ejection of semen from the penis (or the feeling of this). • orgasm is the fulfillment or climax following sexual stimulation or intercourse. Over the past 4 weeks: 0 No sexual activity 1 Almost never or never How often were you able to get an erection during sexual 2 A few times (less than half of the time) 0 Q1 3 Sometime (about half of the time) activity? 4 Most times (more than half of the time) C asJmou always or always o No sexual activity 1 Almost never or never 2 A few times (less than half of the tune) When you had erections with sexual stimulation, how often 0 Q2 3 Sometime (about half of the time) were your erections hard enough for penetration? 4 Most times (more than half of the time) gj Almost always or always 0 DA not attempt intercourse 1 Almost never or never When you attempted intercourse, how often were you able to 2 A few times [less than half of the time) 0 Q3 3 Sometime (about half of the time) penetrate (enter) your partner? 4,4 Most times (more than halt of the time) PAknost always or always 0 Did not attempt intercourse 1 Almost never or never During sexual intercourse, how often were you able to maintain 2 A few times (less than half of the time) 0 Q4 3 Sometime (about half of the time) your erection after you had penetrated (entered) your partner? Most times (more than half of the time) S Almost always or ahvays EFTA00314084